Blocking the effects of cytokines is a potential new therapeutic avenue for the treatment of Gram-negative sepsis. Three classes of agents are currently being evaluated: antibodies, circulating inhibitors, and receptor antagonists. Data in the current literature support the consideration of these agents as potential therapeutic agents in Gram-negative sepsis. The clinical utility of these agents is contingent on the results of well-designed, prospective, randomized, placebo-controlled clinical trials in well-defined clinical populations. These trials will require the cooperation of clinical and basic scientists. At this time, preliminary and early clinical trials are in progress utilizing IL-1 and TNF-alpha circulating inhibitors, IL-1 receptor antagonists, and monoclonal antibodies to TNF-alpha and the TNF-alpha receptor.

Acute myopathy in patients being treated for severe asthma has been recognized with increasing frequency since first being described in 1977. We report three patients treated for status asthmaticus who developed severe generalized weakness. Electrophysiologic studies and muscle biopsy revealed evidence of muscle destruction. Each of these patients was treated with high-dose corticosteroids and underwent prolonged neuromuscular blockade with a steroidal muscle relaxant. A review of the literature revealed 15 similar cases. We postulate that the combined effects of corticosteroids and muscle relaxants on the muscle cell may be responsible for this myopathy. Patients treated with corticosteroids and NMBs should be carefully monitored for the development of myopathy.

There are several bronchiolar diseases with different pathologic and clinical findings. Idiopathic BOOP is a distinct entity consisting of a flu-like illness, late inspiratory crackles, patchy infiltrates roentgenographically, and physiologically decreased vital capacity and diffusing capacity. Response to corticosteroid therapy is good and relapse does not occur if sufficient therapy is given. Bronchiolitis obliterans organizing pneumonia is an appropriate description of this entity. The term is specific because it includes bronchioles and alveoli and excludes disorders involving only alveoli such as organizing pneumonitis or organizing diffuse alveolar damage. The term is general enough to include a sufficient number of patients with a homogenous disorder. Furthermore, the entity can be described to clinicians and pathologists throughout the world in such a fashion that patient care and research can be standardized. Researchers from different centers studying the cause or utilizing treatment protocols are able to discuss a single BOOP entity rather than comparing results of a heterogeneous group of many different types of interstitial lung disorders. This will lead to breakthroughs in discovery of etiologic causes and new effective therapeutic regimens.

Scanty irregular opacities are not uncommonly observed on the chest roentgenogram in the absence of interstitial fibrosis of the lungs. In such circumstances the irregular opacities, when present, tend to be relatively scanty and seldom, if ever, exceed an ILO category of 1/1. They are found in association with cigarette smoking, especially when emphysema is also present. The development of irregular opacities is also related to exposure to various mineral and other dusts, and although their prevalence increases with cumulative dust exposure, in general the type of dust, whether fibrogenic or relatively inert, seems to be of little moment. The presence of irregular opacities remains a troublesome confounding factor in epidemiologic studies of both dust-exposed and nonexposed populations. The morbid anatomic changes that occur in the lungs of nondust-exposed workers and which are responsible for the development of irregular opacities in the chest roentgenogram remain unknown.

The manifestations of cardiac mucormycosis may dominate the clinical picture of disseminated mucormycosis. These manifestations include myocardial infarction, congestive heart failure, conduction system disease, valvular imcompetence and pericarditis. The development of such manifestations in a febrile compromised host with one or more predisposing factors should prompt consideration of disseminated mucormycosis in the differential diagnosis and initiation of appropriate diagnostic and therapeutic strategies.

We evaluated the clinical characteristics of eight patients who presented with vascular erosion from central venous catheters and reviewed the available literature. Patients typically presented with dyspnea or chest pain, unilateral or bilateral pleural effusions, and mediastinal widening one to seven days after catheter insertion. Pleural fluid appeared transudative with variable glucose concentrations (range, 174 to 588 mg/dl) that were always greater than concurrent serum values. Diagnosis was delayed 3.0 +/- 1.5 days (range, 0 to 11 days) after vascular erosion. One patient died and four patients received chest tubes. Seven of eight patients had left-sided line placement; six of these seven left-sided catheters abutted the superior vena cava wall within approximately 45 degrees of perpendicular. Results of a literature search confirm the hazards of delayed diagnosis and the importance of left-sided catheter placement as a risk factor for vascular erosion.